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Experiences with Ceramic Pot Water Filtration Systems in Uganda: a Case Study of the Health and Social Impacts of a Market-Based Approach

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Experiences with Ceramic Pot Water Filtration Systems in Uganda: a Case Study of the Health and Social Impacts of a Market-Based Approach Experiences with ceramic pot water filtration systems in Uganda: A case study of the health and social impacts of a market-based approach by Fantasia Williams A thesis submitted in partial fulfillment of the requirements for the degree of Master of Science / Master of Landscape Architecture (School for Environment and Sustainability) in the University of Michigan May 2020 Thesis Committee: Assistant Professor of Practice, Jose F. Alfaro, PhD Professor, Environmental Health Sciences, Marie S. O'Neill, PhD Abstract: Nearly half of the developing world lacks access to improved sanitation, and millions of individuals lack access to improved drinking water. Following trends of the rest of the developing world, diarrheal diseases are the number one cause of death among children under five years old in Uganda. Among all age groups, diarrhea can still be found among the top ten causes of death, continuously securing the sixth spot over the past ten years. In response, SPOUTS of Water, a Ugandan based NGO, began manufacturing and selling ceramic pot filters as an effective and affordable method of water treatment. Across various locations and over time, evidence has demonstrated that improving water and sanitation conditions can prevent a significant portion of diarrheal disease. The primary objective of this cross-sectional study is to investigate if the usage of the Purifaaya filter in two Ugandan communities is associated with a reduced prevalence of diarrheal disease. After adjustments for the total number of persons in a household, location (urban vs rural), water source, and toilet type, the study found that there was an association between filter use and the reduction in reported diarrheal disease. These results are a roadmap for understanding the potential for water filters to impact environmental and health outcomes in areas similar to that of rural Uganda. ii Table of Contents 1. Introduction ................................................................................................................ iv 1.1 Diarrhea ............................................................................................................... iv 1.2 Diarrhea in Sub-Saharan Africa ............................................................................ iv 1.3 Diarrhea in Uganda ............................................................................................... v 1.4 Purpose of Study ................................................................................................... v 2. Methods ..................................................................................................................... vi 2.1. Cross-sectional study ............................................................................................ vi 2.2 Study Population ................................................................................................... vi 2.3 Household Survey ................................................................................................ vii 2.4. Statistical Analysis .............................................................................................. viii 2.5. Human Subjects Approval ................................................................................... viii 3. Results ...................................................................................................................... viii 3.1. Household Survey ............................................................................................... viii 3.2. Prevalence of Diarrheal Disease ......................................................................... viii 3.3. Experiences with Water Treatment and Filter Use ................................................ x 4. Discussion & Conclusion .............................................................................................. xi iii 1. Introduction Today, diarrheal diseases are a tremendous burden of illness in developing countries. In the last three decades, roughly 2 billion people around the world have gained access to both improved drinking water sources and improved sanitation (Centers for Disease Control and Prevention, 2014a). Still, nearly half of the developing world lacks access to improved sanitation, and millions of individuals lack access to improved drinking water (Centers for Disease Control and Prevention, 2014a; WHO/UNICEF, 2008). Most commonly, food and water contaminated with human or animal feces carry the pathogens that cause diarrhea (Centers for Disease Control and Prevention, 2014a). As a result, in developing countries, unsafe water, inadequate sanitation, and poor hygiene are responsible for approximately 88% of diarrheal related deaths (Centers for Disease Control and Prevention, 2014a). This has a profound impact on children. According to the Center for Disease Control and Prevention (CDC), “Diarrheal diseases kill more children than AIDS, malaria, and measles combined, making it the second leading cause of death among children under five (2014a)”. This number equates to about 525,000 children annually (World Health Organization, 2017). In addition to death, these types of diseases contribute to other conditions such as malnutrition and dehydration, which are both common when the nutrients are lost and not adequately replaced (World Health Organization, 2017). 1.1. Diarrhea Diarrhea is defined as “the passage of three or more loose or liquid stools per day, or more frequently than normal for an individual” (World Health Organization, 2009). The cause of diarrhea can vary but it is most often a symptom of an infection in the intestinal tract caused by a variety of pathogens spread by fecal-oral transmission or contamination from both human and animal sources. (World Health Organization, 2017). These bowel movements can last extended periods and typically flush the body of water and salt until such time that the person can no longer survive unless they are provided with treatment to replenish the water and electrolytes (World Health Organization, 2017). There are three types of diarrhea: acute watery, acute bloody, and persistent (World Health Organization, 2017). Acute watery diarrhea is “associated with significant fluid loss and rapid dehydration in an infected individual” (World Health Organization, 2009). V. cholerae, Escherichia coli (E. coli), and rotavirus are the pathogens most commonly responsible for this type of diarrhea (World Health Organization, 2009). Acute bloody diarrhea usually lasts from several hours to several days. It is also often referred to as dysentery and consists of “visible blood in the stools” (World Health Organization, 2009). This symptom is associated with severe intestinal damage and nutrient loss caused by an infection. The most severe cases of bloody diarrhea are typically caused by the bacteria Shigella (World Health Organization, 2009). Persistent diarrhea can consist of symptoms from either the acute watery or acute bloody types but last at least 14 days (World Health Organization, 2009). 1.2. Diarrhea in Sub-Saharan Africa Sub-Saharan Africa is facing some of the world’s greatest water and sanitation challenges (WHO/UNICEF, 2008), and half of its population is expected to remain rural until at least 2030 (UN, 2007). Urban and rural areas share some of the same institutional and technical challenges in sustaining clean water. However, rural areas face additional challenges associated with a lack iv of roads, telecommunications, electricity, and the general absence of a formal small business sector (Montgomery, Bartram, and Elimelech, 2009). 1.3. Diarrhea in Uganda Currently, 61 % of Ugandans lack access to safe water (Water.org, 2018). With Uganda’s population of 42.8 million people, this equates to more than 26 million people based on 2017 population estimates by the Ugandan Population Reference Bureau (Centers for Disease Control and Prevention, 2017). Following trends of the rest of the developing world, diarrheal diseases are the number one cause of death among children under five years old in Uganda (Centers for Disease Control and Prevention, 2017). Among all age groups, diarrhea can still be found among the top ten causes of death, continuously securing the sixth spot over the past ten years (Institute for Health Metrics and Evaluation, 2017). In rural Uganda, the five main types of water sources that are generally used include traditional water sources, improved point water sources, shallow wells, protected springs, and gravity-flow tap stands (Asingwire, 2011). Traditional water sources like ponds and open wells are considered unsafe, but oftentimes users must resort to using them when faced with barriers to safer sources such as long distances and lack of adequate transportation. Improved drinking water sources include sources that, “by nature of their construction or through active intervention, are protected from outside contamination, particularly fecal matter” (WHO/UNICEF, 2008). Although these supplies are protected from contamination, they are not necessarily free of pathogens (WHO/UNICEF, 2008). Point water sources in Uganda prompt rivalry between community members, as they are usually collectively owned, managed, and used (Poteete, Janssen, and Ostrom 2010). These communal arrangements make it hard to control for unauthorized users and combat against the tragedy of the commons. The most common pathogens responsible for severe diarrhea in low-income countries are Rotavirus and Escherichia coli (World Health Organization, 2017). In Uganda, the most common agent
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